Rehabilitation of somatoparaphrenia with misoplegia: insights from a single case-pilot study.

Somatoparaphrenia lacka ownership of a paralyzed limb, i.e., the illusion that one's limbs belong to someone else. Somatoparaphrenia is one of the many forms of body misperceptions. We report a case of somatoparaphrenia with misoplegia, characterized by the absence of anosognosia for hemiplegia and personal neglect, following a surgical operation for left parietal meningioma. The patient received a novel multidisciplinary treatment, including motor rehabilitation training, traditional physiotherapy and robotic rehabilitation using the Hunova Movendo Technology and psychological counseling. At the end of the training, the patient improved in global cognitive functioning, mood, motor abilities, and the perception of herself and her body, reducing the sense of estrangement and repulsion in the lower right limb. Our result showed the importance of a specific neuropsychological assessment in patients with parietal brain lesions and the usefulness of an integrated psychological and motor approach in rehabilitating patients with somatoparaphrenia, primarily when associated with misoplegia.

Paving the way for a better management of pain in patients with spinal cord injury: An exploratory study on the use of Functional Electric Stimulation(FES)-cycling.

CONTEXT/OBJECTIVE: Chronic pain is common in patients with spinal cord injury (SCI), for whom it negatively affects quality of life, and its treatment requires an integrated approach. To this end, lower limb functional electrical stimulation (FES) cycling holds promise. OBJECTIVE: To investigate pain reduction in a sample of patients with SCI by means of lower limb rehabilitation using FES cycling. DESIGN, SETTING AND PARTICIPANTS: Sixteen patients with incomplete and complete SCIs, attending the Neurorobotic Unit of our research institute and reporting pain at or below the level of their SCI were recruited to this exploratory study. INTERVENTIONS: Patients undertook two daily sessions of FES cycling, six times weekly, for 6 weeks. OUTCOME MEASURES: Pain outcomes were measured using the 0-10 numerical rating scale (NRS), the Multidimensional Pain Inventory for SCI (MPI-SCI), and the 36-Item Short Form Survey (SF-36). Finally, we assessed the features of dorsal laser-evoked potentials (LEPs) to objectively evaluate Aδ fiber pathways. RESULTS: All participants tolerated the intervention well, and completed the training without side effects. Statistically significant changes were found in pain-NRS, MPI-SCI, and SF-36 scores, and LEP amplitudes. Following treatment, we found that three patients experienced high pain relief (an NRS decrease of at least 80%), six individuals achieved moderate pain relief (an NRS decrease of about 30-70%), and five participants had mild pain relief (an NRS decrease of less than 30%). CONCLUSION: Our preliminary results suggest that FES cycling training is capable of reducing the pain reported by patients with SCI, regardless of American Spinal Injury Association scoring, pain level, or the neurological level of injury. The neurophysiological mechanisms underlying such effects are likely to be both spinal and supraspinal.

When Two Is Better Than One: A Pilot Study on Transcranial Magnetic Stimulation Plus Muscle Vibration in Treating Chronic Pelvic Pain in Women.

Chronic pelvic pain syndrome (CPPS) affects about 4-16% of adult women, and about one-third of them require medical assistance due to severe symptoms. Repetitive transcranial magnetic stimulation (rTMS) over the supplementary motor area (SMA) has been shown to manage pain in refractory CPPS. Focal muscle vibration (FMV) has also been reported to relieve pelvic pain. The objective of this study was to assess the feasibility and effect of rTMS coupled with FMV to reduce pain in seven adult women with refractory CPPS. This pilot, open-labeled, prospective trial examined treatment by 5 Hz rTMS over SMA and 150 Hz FMV over the perineum, suprapubic, and sacrococcygeal areas, with one daily session for five consecutive days for three weeks. We assessed tolerance and subjective pain changes (as per visual analog scale, VAS) until one month post-treatment, with a primary endpoint at day 7. No patients experienced serious adverse effects or a significant increase in pain. Six out of seven patients experienced a VAS improvement of at least 10% at T7; three of these individuals experienced a VAS improvement of more than 30%. Overall, we found a significant VAS reduction of 15 points (95% CI 8.4-21.6) at T7 (t = 6.3, p = 0.001; ES = 2.3 (1.1-3.9)). Three of the women who demonstrated a significant VAS reduction at T7 retained such VAS improvement at T30. VAS decreased by six points (95% CI 1.3-10.7) at T30 (t = 3.1, p = 0.02; ES = 1.5 (0.2-2.6)). This coupled approach seems promising for pain management in adult women with refractory CPPS and paves the way for future randomized controlled trials.

Improving Upper Extremity Bradykinesia in Parkinson's Disease: A Randomized Clinical Trial on the Use of Gravity-Supporting Exoskeletons.

Hand movements are particularly impaired in patients with Parkinson's Disease (PD), contributing to functional disability and difficulties in activities of daily living. Growing evidence has shown that robot-assisted therapy may be considered an effective and reliable method for the delivery of the highly repetitive training that is needed to trigger neuroplasticity, as intensive, repetitive and task-oriented training could be an ideal strategy to facilitate the relearning of motor function and to minimize motor deficit. The purpose of this study is to evaluate the improvement of hand function with semi-autonomous exercises using an upper extremity exoskeleton in patients with PD. A multicenter, parallel-group, randomized clinical trial was then carried out at the IRCCS Centro Neurolesi Bonino-Pulejo (Messina, Italy). Thirty subjects with a diagnosis of PD and a Hoehn-Yahr score between 2 and 3 were enrolled in the study. Patients were 1:1 randomized into either the experimental group (ERT), receiving 45 min training daily, 6 days weekly, for 8 weeks with Armeo®Spring (Volketswil, Switzerland) (a gravity-supporting device), or the control group (CPT), which was subjected to the same amount of conventional physical therapy. Motor abilities were assessed before and after the end of the training. The main outcomes measures were the Nine-hole peg test and the motor section of the UPDRS. All patients belonging to ERT and 9 out of 15 patients belonging to the CPT completed the trial. ERT showed a greater improvement in the primary outcome measure (nine-hole peg test) than CPT. Moreover, a statistically significant improvement was found in ERT concerning upper limb mobility, and disease burden as compared to CPT. Using an upper extremity exoskeleton (i.e., the Armeo®Spring) for semi-autonomous training in an inpatient setting is a new perspective to train patients with PD to improve their dexterity, executive function and, potentially, quality of life.

Toward improving functional recovery in spinal cord injury using robotics: a pilot study focusing on ankle rehabilitation.

BACKGROUND: Conventional physical therapy interventions are strongly recommended to improve ambulation potential and upright mobility in persons with incomplete spinal cord injury (iSCI). Ankle rehabilitation plays a significant role, as it aims to stem drop foot consequences. RESEARCH QUESTION: This pilot study aimed to assess the neurophysiological underpinnings of robot-aided ankle rehabilitation (using a platform robot) compared to conventional physiotherapy and its efficacy in improving gait performance and balance in persons with iSCI. METHODS: Ten individuals with subacute/chronic iSCI (six males and four females, 39 ± 13 years, time since injury 8 ± 4 months, ASIA impairment scale grade C-D) were provided with one-month intensive training for robot-aided ankle rehabilitation (24 sessions, 1 h daily, six times a week). Clinical (10-Meter Walk Test (10MWT), 6-Minute Walk Test (6MWT), and Timed Up and Go test (TUG)), and electrophysiological aftereffects (surface-EMG from tibialis anterior and medial gastrocnemius muscles to estimate muscle activation patterns; and corticomuscular coherence-CMC-to assess functional synchronization between sensorimotor cortex and muscles, i.e. the functional integrity of corticospinal output) were assessed at baseline (PRE) and after the trial completion (POST). The experimental group (EG) data were compared with those coming from a retrospective control group (CG; n = 10) matched for clinical-demographic characteristics, who previously underwent conventional ankle rehabilitation. RESULTS: the EG achieved a greater improvement in balance and gait as compared to the CG (TUG EG from 70 ± 18 to 45 ± 15 s, p = 0.002; CG from 68 ± 21 to 48 ± 18 s, p = 0.01; group-comparison p = 0.001; 10MWT EG from 0.43 ± 0.11 to 0.51 ± 0.09 m/s, p = 0.006; CG from 0.4 ± 0.13 to 0.45 ± 0.12, p = 0.01; group-comparison p = 0.006; 6 MWT EG from 231 ± 13 to 274 ± 15 m, p < 0.001; CG from 236 ± 13 to 262 ± 15 m, p = 0.003; group-comparison p = 0.01). Furthermore, the EG showed a retraining of muscle activation (an increase within proper movements, with a reduction of co-contractions) and CMC (beta frequency increase within proper movements, i.e. in a framework of preserved motor coordination). The improvements in CMC, gait, balance, and muscle activation were not correlated with each other. CONCLUSIONS: Robot-aided ankle rehabilitation improved gait performance by selectively ameliorating CMC, muscle activation patterns, and, lastly, gait balance and speed. Despite CMC, gait, balance, and muscle activation were not correlated, this pilot study suggests that robot-aided ankle rehabilitation may favor a better communication between above-SCI and below-SCI structures. This communication improvement may depend on a more synchronized corticospinal output (as per CMC increase) and a better responsiveness of below-SCI motorneurons to corticospinal output (as per specific and ankle movement focused muscle activation increases at the surface EMG), thus favoring greater recruitment of spinal motor units and, ultimately, improving muscle activation pattern and strength. SIGNIFICANCE: Adopting robot-aided ankle rehabilitation protocols for persons with iSCI in the subacute/chronic phase may allow achieving a clinically significant improvement in gait performance.

How may patients with MS benefit from using music assisted therapy? A case-control feasability study investigating motor outcomes and beyond.

Motor impairment is the most common symptom in multiple sclerosis (MS), as gait and balance dysfunction are reported in more than 85% of the patients, with considerable consequences on the patient's activities of daily living and psychological status. This study aimed at evaluating the feasibility and potential efficacy of a novel treatment involving music plus treadmill in patients with MS. Ten patients affected by secondary progressive MS were submitted to a specific training using the Gait Trainer (GT) 3, a platform that integrates gait training via a treadmill and rhythmic auditory stimulation. The 30 minutes training was performed three times per week for eight weeks (24 sessions in total). The enrolled patients were compared with a control group (CG) of 10 patients with MS matched for age, gender, disease duration, and EDSS stage. The CG received the same amount of treatment, but using conventional overground gait training. All patients completed the training without reporting any side effects. At the end of the training, CG improved in static and dynamic balance and in mood. Instead, in the EG a significant improvement in static and dynamic balance, walking speed, and mobility, as well as in mood, and perception of quality of life (QoL), both for physical and mental well-being, was found. This exploratory study suggests that GT3 might be a feasible and potentially useful approach for MS gait rehabilitation, thanks to patients' high motivation and good acceptance of the music assisted therapy.

Can powered exoskeletons improve gait and balance in multiple sclerosis? A retrospective study.

Multiple sclerosis (MS) is a progressive neurologic disorder that can profoundly influence mobility, independence and quality of life. Gait dysfunction in MS is common, resulting in an increased risk of losing walking ability. Robotic exoskeletons have been developed to offer a new form of locomotor training. The aim of our study was to investigate the effectiveness of the powered exoskeleton (Ekso) in improving gait and balance in patients affected by MS. Twenty patients with MS (mean ± SD: age = 43.7 ± 10.3 years; 66.7% male) were enrolled in this retrospective study. They were divided into two groups, matched for demographic data (age and sex) and medical characteristics (disease duration and Expanded Disability Status Scale), but differing for the type of rehabilitation training performed. Group 1 [experimental group (EG)] received gait training with the Ekso device, whereas group 2 (control group) performed traditional gait training. Although both trainings led to a significant improvement in the ability to walk and balance, only in the EG a significant improvement in walking speed (10 Meter Walk test; P = 0.002), in person's mobility (Timed Up and Go test; P = 0.002), and in the perception of mental well-being (MSQoL-M; P = 0.004), with a good usability and acceptance of the device, was found. Powered exoskeletons could be considered a valuable tool to improve functional outcomes and get the therapeutic goal in patients with MS.

Beyond motor recovery after stroke: The role of hand robotic rehabilitation plus virtual reality in improving cognitive function.

Robot-assisted hand training adopting end-effector devices results in an additional reduction of motor impairment in comparison to usual care alone in different stages of stroke recovery. These devices often allow the patient to perform practical, attentive, and visual-spatial tasks in a semi-virtual reality (VR) setting. We aimed to investigate whether the hand end-effector robotic device AmadeoTM could improve cognitive performance, beyond the motor deficit, as compared to the same amount of occupational treatment focused on the hand. Forty-eight patients (aged 54.3 ±â€¯10.5 years, 62.5% female) affected by either ischemic or hemorrhagic stroke in the chronic phase were enrolled in the study. The experimental group (EG) underwent AmadeoTM robotic training, while the control group (CG) performed occupational therapy involving the upper limb. Patients were assessed at the beginning and at the end of the rehabilitation protocol using a specific neuropsychological battery, as well as motor function tests. The EG showed greater improvements in different cognitive domains, including attentive abilities and executive functions, as well as in hand motor function, as compared to CG. Our study showed that task-oriented VR-based robotic rehabilitation enhanced not only motor function in the paretic arm but also global and specific cognitive abilities in post-stroke patients. We may argue that the hand robotic plus VR-based training may provide patients with an integration of cognitive and motor skill rehabilitation, thus amplifying the functional outcome achievement.

A Case of Psychogenic Myoclonus Responding to a Novel Transcranial Magnetic Stimulation Approach: Rationale, Feasibility, and Possible Neurophysiological Basis.

Repetitive transcranial magnetic stimulation (rTMS) can relieve motor symptoms related to psychogenic movement disorders (PMDs), but the subtending neurophysiological basis is unclear. We report on a 50-year-old woman with a diagnosis of psychogenic myoclonus in the right lower limb, who was treated with a daily session (in the late morning/early afternoon) of 1 Hz rTMS over the left premotor cortex (PMC), five times a week for 6 weeks. Clinical data and EEG at rest were collected before and immediately and 2-month after the rTMS protocol completion. The patient reported a significant reduction of involuntary movement frequency and intensity and the related disability burden up to the follow-up. In parallel, any abnormality in terms of source current density within and connectivity between the frontal and parietal areas was reset. The short follow-up period, the lack of extensive neurophysiological measures, and the lack of control treatment represent the main limitation of the study. However, low-frequency rTMS over PMC seems a safe and promising approach for the management of psychogenic myoclonus owing to the combination of cortical neuromodulation and non-specific mechanisms suggesting cognitive-behavioral effects.

Can emerging technologies be effective in improving alexithymia due to brain lesion?: Lessons from a case report.

INTRODUCTION: About 66% of stroke survivors present with cognitive or physical consequences, which are often complicated by emotional instability. Alexithymia is defined as "a difficulty in identifying and describing feelings", although there is no consensus on the exact diagnosis and treatment. PATIENT CONCERNS: A 36-year-old right-handed man, affected by ischemic stroke (which occurred about 3 months before admission) involving the right hemisphere (ie, the fronto-parieto-temporal region) with left hemiparesis and behavioral abnormalities, came to our observation for intensive rehabilitation. He was treated unsuccessfully with a traditional and behavioral training. DIAGNOSIS: Alexithymia due to ischemic stroke. INTERVENTIONS: Then, a specific combined protocol using computerized emotional and virtual emotional training was applied in a semi-immersive virtual reality environment using the BTS-Nirvana device. OUTCOMES: At the end of this novel rehabilitation approach, the patient showed a significant improvement in emotional skills, cognitive performances, and coping strategies. CONCLUSIONS: Virtual reality, in addition to standard therapy, may be a valuable tool in improving emotional abnormalities due to brain lesions, such as alexithymia.

Effects of osteopathic manipulative treatment on patients with multiple sclerosis: A pilot study.

OBJECTIVES: To describe the effects of osteopathic manipulative treatment in patients affected by Multiple Sclerosis (MS). DESIGN AND SETTING: This is a pilot study involving 20 MS patients attending the IRCCS Neurolesi "Bonino-Pulejo", Messina, Italy. INTERVENTION: The clinical evaluation was performed before starting rehabilitation treatment (T0) and after 8 weeks of treatment (T1). The CG sample undergo a conventional rehabilitation training (CRT), 5 times/week for 60 min (for a total of 40 sessions), the EG performed the same CRT (but with a different frequency, i.e. 3 times/week, for a total of 24 sessions) and a specific OMT 2 times/week for 60 min (for a total of 16 sessions). MAIN OUTCOME MEASURES: We analyzed the scores recorded in the following main scales: Expanded Disability Status Scale (EDSS), 10 m walking test (10mWT), Hamilton anxiety rating scale (HRS-A), and the Fatigue severity scale (FSS). RESULTS: Our data showed a reduction in the FSS score for the EG (40 ± 1,41 at T0 vs 37 ± 2,32 at T1; p = 0.04) but not in the CG (41 ± 2,41 at TO vs 39 ± 2,6 at T1) with an intergroup difference p < 0.00. An improvement of HRS-A and 10mWT was also detected in the EG. CONCLUSIONS: Our data raise idea that OMT might be useful in rehabilitative setting in MS patients, with particular regard to anxiety and fatigue.

Improving Sexual Function by Using Focal Vibrations in Men with Spinal Cord Injury: Encouraging Findings from a Feasibility Study.

Erectile dysfunction (ED) is a frequent and disabling condition in patients with spinal cord injury (SCI). Spasticity can negatively affect sexual intercourse, as it may interfere with positioning, mobility, and muscle activation and strength, leading to ED. The aim of our study was to evaluate the feasibility and efficacy of muscle vibration (MV) applied to the pelvic muscles in improving ED in men with SCI. Ten adult men with traumatic SCI were submitted to 15 sessions of MV, applied on the perineum and the suprapubic and sacrococcygeal areas, using a pneumatic vibrator. MV was performed three times a week for five consecutive weeks, each session lasting 30 min. Muscle tone and sexual function were assessed before and after MV using the Modified Ashworth Scale (MAS) and International Index of Erectile Function (IIEF). We assessed the cremasteric and bulbocavernosus reflexes, as well as the electrophysiological bulbocavernosus reflex (eBCR) and pudendal nerve somatosensory-evoked potential (PSEP). MV was safe and well tolerated. All the patients reported an improvement in MAS and IIEF, with better reflexive responses, and a significant increase in eBCR and PSEP amplitude. In conclusion, MV of the pelvic floor is a promising method to reduce segmental spasticity and improve ED in men with incomplete SCI. However, our findings require confirmation through a randomized clinical trial with a larger sample size and longer trial period to examine long-term after effects.

The Growing Use of Virtual Reality in Cognitive Rehabilitation: Fact, Fake or Vision? A Scoping Review.

OBJECTIVE: This review aims to evaluate the role of Virtual Reality (VR) in cognitive rehabilitation of different neurological diseases, and the accessibility to healthcare systems providing this type of treatment. METHOD OF RESEARCH: Studies performed between 2003 and 2017 and fulfilling the selected criteria were found on PubMed, Scopus, Cochrane and Web of Sciences databases. The search combined the terms VR rehabilitation with different neurological disease. RESULTS: Our findings showed that neurological patients performed significant improvement in many cognitive domains (executive and visual-spatial abilities; speech, attention and memory skills) following the use of VR training. CONCLUSIONS: This review supports the idea that rehabilitation through new VR tools could positively affect neurological patients' outcomes, by boosting motivation and participation so to get a better response to treatment. In particular, VR can be used to enhance the effects of conventional therapies, promoting longer training sessions and a reduction in overall hospitalization time.

Does hand robotic rehabilitation improve motor function by rebalancing interhemispheric connectivity after chronic stroke? Encouraging data from a randomised-clinical-trial.

OBJECTIVE: The objective of this study was the evaluation of the clinical and neurophysiological effects of intensive robot-assisted hand therapy compared to intensive occupational therapy in the chronic recovery phase after stroke. METHODS: 50 patients with a first-ever stroke occurred at least six months before, were enrolled and randomised into two groups. The experimental group was provided with the Amadeo™ hand training (AHT), whereas the control group underwent occupational therapist-guided conventional hand training (CHT). Both of the groups received 40 hand training sessions (robotic and conventional, respectively) of 45 min each, 5 times a week, for 8 consecutive weeks. All of the participants underwent a clinical and electrophysiological assessment (task-related coherence, TRCoh, and short-latency afferent inhibition, SAI) at baseline and after the completion of the training. RESULTS: The AHT group presented improvements in both of the primary outcomes (Fugl-Meyer Assessment for of Upper Extremity and the Nine-Hole Peg Test) greater than CHT (both p < 0.001). These results were paralleled by a larger increase in the frontoparietal TRCoh in the AHT than in the CHT group (p < 0.001) and a greater rebalance between the SAI of both the hemispheres (p < 0.001). CONCLUSIONS: These data suggest a wider remodelling of sensorimotor plasticity and interhemispheric inhibition between sensorimotor cortices in the AHT compared to the CHT group. SIGNIFICANCE: These results provide neurophysiological support for the therapeutic impact of intensive robot-assisted treatment on hand function recovery in individuals with chronic stroke.

Cognitive rehabilitation in patients with traumatic brain injury: A narrative review on the emerging use of virtual reality.

Traumatic brain injury (TBI) is a clinical condition characterized by brain damage due to an external, rapid and violent force. TBI causes attention, memory, affectivity, behaviour, planning, and executive dysfunctions, with a significant impact on the quality of life of the patient and of his/her family. Cognitive and motor rehabilitation programs are essential for clinical recovery of TBI patients, improving functional outcomes and the quality of life. Various researches have underlined the possible effectiveness of innovative techniques, with regard to virtual reality (VR), during the different phases of rehabilitation after TBI. This review aims to evaluate the role of VR tools in cognitive assessment and rehabilitation in individuals affected by TBI. Studies performed between 2010 and 2017 and fulfilling the selected criteria were found on PubMed, Scopus, Cochrane and Web of Sciences databases. The search combined the terms VR, assessment, rehabilitation and TBI. Our review has shown that VR has the potential to provide an effective assessment and rehabilitation tool for the treatment of cognitive and behavioral impairment on TBI patients.

The role of robotic gait training coupled with virtual reality in boosting the rehabilitative outcomes in patients with multiple sclerosis.

Motor impairment is the most common symptom in multiple sclerosis (MS). Thus, a variety of new rehabilitative strategies, including robotic gait training, have been implemented, showing their effectiveness. The aim of our study was to investigate whether an intensive robotic gait training, preceding a traditional rehabilitative treatment, could be useful in improving and potentiating motor performance in MS patients. Forty-five patients, who fulfilled the inclusion criteria, were enrolled in this study and randomized into either the control group (CG) or the experimental group (EG). A complete clinical evaluation, including the Expanded Disability Severity Scale, the Functional Independence Measure, the Hamilton Rating Scale for Depression, the time up and go test (TUG), and the Tinetti balance scale, was performed at baseline (T0), after 6 week (T1), at the end of rehabilitative training (T2), and 1 month later (T3). A significant improvement was observed in the EG for all the outcome measures, whereas the CG showed an improvement only in TUG. In contrast, from T1 to T2, only CG significantly improved in all outcomes, whereas the EG had an improvement only regarding TUG. From T2 to T3, no significant differences in Functional Independence Measure scores emerged for both the groups, but a significant worsening in Tinetti balance scale and TUG was observed for the CG and in TUG for the EG. Our study provides evidence that robotic rehabilitationn coupled with two-dimensional virtual reality may be a valuable tool in promoting functional recovery in patients with MS.

Breakthroughs in the spasticity management: Are non-pharmacological treatments the future?

The present paper aims at providing an objective narrative review of the existing non-pharmacological treatments for spasticity. Whereas pharmacologic and conventional physiotherapy approaches result well effective in managing spasticity due to stroke, multiple sclerosis, traumatic brain injury, cerebral palsy and incomplete spinal cord injury, the real usefulness of the non-pharmacological ones is still debated. We performed a narrative literature review of the contribution of non-pharmacological treatments to spasticity management, focusing on the role of non-invasive neurostimulation protocols (NINM). Spasticity therapeutic options available to the physicians include various pharmacological and non-pharmacological approaches (including NINM and vibration therapy), aimed at achieving functional goals for patients and their caregivers. A successful treatment of spasticity depends on a clear comprehension of the underlying pathophysiology, the natural history, and the impact on patient's performances. Even though further studies aimed at validating non-pharmacological treatments for spasticity should be fostered, there is growing evidence supporting the usefulness of non-pharmacologic approaches in significantly helping conventional treatments (physiotherapy and drugs) to reduce spasticity and improving patient's quality of life. Hence, non-pharmacological treatments should be considered as a crucial part of an effective management of spasticity.